One of the eligibility groups that benefits perhaps the most from SoonerCare is pregnant women, however, coverage is slightly different for them than other applicants. While you are pregnant, you have access to all of the traditional SoonerCare services offered to others who normally qualify, but because the income guidelines are higher for pregnant women, you may not be able to continue your coverage after your maternity benefits end. Coverage lasts for the duration of your pregnancy, delivery, and the first few months after birth. Newborns to mothers on SoonerCare for pregnant women automatically qualify for coverage, and are enrolled as soon as you notify the program of your child’s birth.
For those who are unsure if they qualify for benefits, there is a Presumptive Eligibility program in Oklahoma to cover prenatal care for the length of time it takes for a SoonerCare application to be approved. This program helps women get immediate access to the care they need to stay healthy while pregnant.
Another program is available specifically for illegal immigrants and documented immigrant women who are pregnant and do not qualify for Medicaid, which is called Soon-to-be-Sooners. Created in 2008, this program has gathered funding to keep immigrant women and their newborns in good health by providing prenatal care and a safe delivery.
Women with income less than or equal to 185 percent of the federal poverty level, or $27,991 annually for a family of two, will be able to obtain health insurance for their pregnancy through SoonerCare. When applying for the program, you must provide the program with pregnancy test results from a qualified physician to confirm your need for coverage. You must also meet the residency guidelines, such as being an Oklahoma resident and a U.S. citizen or legal immigrant, unless seeking the Soon-to-be-Sooners program.
The same rules apply when enrolling in Presumptive Eligibility and Soon-to-be-Sooners (with exception to citizenship), as you will complete an application for regular SoonerCare in order to use these programs. A pregnant woman is considered two people when applying for coverage, and add any additional members of the household including a spouse or other children in figuring the income level.
Income Guidelines – 185% FPL
Family of 2: $2,333 monthly, $27,991 yearly
Family of 3: $2,943 monthly, $35,317 yearly
Family of 4: $3,554 monthly, $42,643 yearly
Family of 5: $4,164 monthly, $49,969 yearly
Family of 6: $4,775 monthly, $57,295 yearly
Family of 7: $5,385 monthly, $64,621 yearly
Family of 8: $5,996 monthly, $71,947 yearly
Households over 8 persons add $3,690 for each additional family member.
In addition to maternity services, those who are members of SoonerCare during their pregnancy have access to all of the benefits included with a full Medicaid plan. This includes physician office visits, hospital care, medical supplies, and other services unrelated to pregnancy if needed. Certain services may require a referral or pre-approval from your primary care doctor, and some may be offered for a copay.
Obstetrical services through SoonerCare and Soon-to-be-Sooners vary based on accessibility and limits placed on certain services. Some benefits are only available to SoonerCare members, and others are only offered if the patient is approved for medical necessity. Below are the possible OB/GYN services offered through SoonerCare or Soon-to-be-Sooners. Other covered medical services can be viewed here.
- Breastfeeding counseling services
- Dental coverage while pregnant (limited for SoonerCare, not available for Soon-to-be-Sooners)
- Diabetes supplies
- Diagnostic and lab work for pregnancy
- Genetic counseling
- High risk obstetric care (if medically necessary)
- Labor and delivery
- Maternal and infant health social work
- Routine office visits
- Tobacco cessation
The state of Oklahoma now covers pregnant women who are immigrants that do not qualify for regular Medicaid because of residency requirements. This limited benefit coverage will last throughout the pregnancy and end upon delivery. In order to qualify, you must prove your pregnancy through a doctor, and have no other source of health insurance.
Primarily, services include the most essential services to provide for maintaining good health while pregnant. These include prenatal office visits, labs and diagnostic work related to the pregnancy, hospital services for labor, delivery, and the newborn, and the other benefits indicated above. Members also have access to the Patient Advice Line.
One postpartum visit is covered for the mother when provided as part of the CPT billing code 59400, though otherwise services after birth are not covered. Newborns will have access to full coverage through SoonerCare, as they are U.S. citizens and can be enrolled for their first 12 months of life. One their first birthday, the child will need to have another application form submitted for the following coverage year.
How to Apply
PE, SoonerCare, and Soon-to-be-Sooners all use the same application through the Oklahoma Health Care Authority. You may apply for benefits online or mail a completed paper form with necessary documents included (such as proof of pregnancy) to the OHCA at:
Oklahoma Health Care Authority
PO Box 548804
Oklahoma City, OK 73154
Once your application is received, you will be notified of your approval or denial, or whether more documentation is needed to determine eligibility. If you are approved, you will select a primary care physician from the list of SoonerCare providers, which can be an OB/GYN so long as they are contracted with the program. View a list of providers in the state.
800 987 7767
1. OHCA. “Pregnancy Services.” http://www.okhca.org/individuals.aspx?id=12496&menu=42&parts=12497
2. OHCA. “Soon-to-be-Sooners.” www.okhca.org/powerpoint/STBS_OHCA_Web.ppt